FREQUENTLY ASKED QUESTIONS
Tongue ties seem to be one of the most polarizing topics in medicine and dentistry. It seems like everyone is on a different page and has a different opinion on the diagnosis, treatment, and management of tongue ties. Since we often hear the same questions asked over and over, this section will aim to provide answers to those questions from Dr. Aaronson's perspective.
My child is 2 months old - why hasn't anyone mentioned tongue tie before?
The simplest answer is that, unfortunately, nobody has probably looked to see if your child even has a tongue tie. Or they "looked" by peeking into the mouth, having the baby suck their finger, or commented that the baby can stick their tongue out so they aren't tongue tied. The only way to diagnose a tongue tie is by using your fingers to lift the baby's tongue and to evaluate whether there is tension under the tongue that is preventing the full movement and function of the tongue. This goes hand in hand with a full functional evaluation by a tie-savvy lactation consultant or feeding specialist, such as an IBCLC, CLC, SLP or OT.
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Tongue ties are barely mentioned in dental or medical school (if at all) and there is no training in the diagnosis or treatment of ties. We have heard from many physicians that tongue ties are a "fad" and that they don't actually impact breastfeeding. In order to learn about tongue ties, a provider needs to seek out additional training to learn the biology, physiology, impact on breastfeeding, safe treatment, and post-operative management of tethered oral tissues.
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So many symptoms, such as gas, nipple pain, latching difficulties, falling asleep at the breast and poor weight gain are seen as "normal" in the early days of breastfeeding. When the symptoms continue, frustrated parents often turn to other sources such as social media, Google, and friends to see if anyone else has experienced similar problems. We often hear mothers tell us that they struggled for weeks with breastfeeding, and only once they reached out to a tie-savvy IBCLC did they finally hear the words "tongue tie" mentioned, and upon learning how tongue ties can impact feeding, all the struggles they have faced finally seem to make sense.
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Right around 2 months of age, several key changes happen that can cause an already precarious breastfeeding situation to suddenly worsen. Around this time, the infant's suck reflex integrates (meaning what started out as a reflexive suck becomes a willing suck), and if a baby is struggling to latch onto the bottle or breast, they often get more frustrated during feeds. It is also around this time that the mother's milk supply, which starts out as hormonally-driven from the changes during pregnancy and birth, becomes driven by supply-and-demand. And if the infant isn't latching well, there is insufficient suction on the breast, which causes milk supply to decrease. As the infant gets bigger, their caloric needs increase. So a lower milk supply in mom, combined with a baby who is frustrated when trying to latch, often leads to lots of tear from both mom and baby. This is often why tongue ties go unchecked for several weeks, because symptoms aren't significant enough to raise any red flags with the pediatrician, or the symptoms become the diagnosis (such as reflux and colic).
Why is it so important to diagnose and treat early? The Donati-Bourne (2015) study showed that delaying treatment beyond 4 weeks from referral to assessment of neonatal tongue tie is more likely to be associated with abandonment of breast feeding. The sooner tongue ties are treated, the more predictable the outcome as it relates to latching and feeding.
My child is gaining weight, so we were told the tongue tie isn't affecting him. Is that true?
Babies are not livestock!! Weight gain is not the only criteria for successful feeding! In many cases, the mother has an oversupply that is masking a lot of the baby's symptoms. It's almost like the baby is filling up at a gas station, where the milk is just pouring into their mouth and they're chugging and gulping, often choking and coughing, and since the milk makes it to their belly, they gain weight. But that doesn't come without a lot of other symptoms that result from that gulping! Babies who are taking in a lot of air often end up being very gassy and colicky. They grunt and stiffen after eating, and the bubbles in their belly can lead to reflux, sneezing, congestion, and hiccups. Just because your baby is gaining weight does not mean they are thriving! If your baby is uncomfortable after feeds, try to figure out why!
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The 2016 Siegel study showed a correlation between lip/tongue tie and reflux. In this study, over 70% of babies who had been diagnosed with reflux showed improvement of reflux symptoms after their tongue and/or lip ties were treated (and 50% of the babies were completely weaned off their reflux medications.)
What about that New York Times article that says tongue ties are overtreated?
A 2024 New York Times article accused dentists of over-treatment and taking advantage of vulnerable moms and babies, suggesting that they do so for financial gain. We have even heard that some pediatricians are pointing to the article as a reason parents should ignore obvious tongue ties that are impacting their child's growth and development, because the article ignores all the value, scientifically-sound research that supports the existence and treatment of tongue ties. Unfortunately, this has created so much conflict for parents, that they often choose to delay or avoid necessary treatment of tongue ties and both they and their child suffer as a result.
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The bottom line is that the article focused on a very small number of cases where the families did not have a positive outcome after treatment. There is no mention of the thousands of valid, peer-reviewed studies that showed the benefit of treatment (when indicated.) Instead, this article created significant doubt for both parents and pediatricians, and this unfortunately has led to long term negative outcomes for the families that were not given the proper information to allow them to make an educated decision on their child's care.
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This post from Dr. Richard Baxter goes into more detail as to why the New York Times article is so damaging. https://tonguetieal.com/the-real-story-of-the-booming-business-of-tongue-tie-nyt-article-response/. Here is part of his response:
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"Here’s the TRUE story that is worth publishing. Every day, countless tongue-tie release providers help families not just in the USA but around the world whom the medical establishment has failed and dismissed. Many well-meaning primary care providers say that reflux, colic, spitting up, gassiness, nipple pain, trouble bottle-feeding, and more are all “normal.” They say that speech delay, slow and picky eating, choking on solids, sleep-disordered breathing, snoring, and teeth grinding are “normal” as well... None of these things are normal or optimal but rather common. Just like cavities in teeth are common, but certainly not normal. So, the babies struggle until the moms hear about a potential fix for the issues they are struggling with, which can also worsen post-partum depression for many mothers (and mothers often see improvement after a proper tongue-tie release when we assess them with a validated EPDS-10 questionnaire).
"The babies who don’t get treatment sadly do not outgrow a restricted tongue but can often (not always) have issues with speech, eating, sleep, and more. The confounding factor is that not all tongue-tied patients have speech or breastfeeding difficulties, just like not every patient who had COVID ended up in the ICU or had significant symptoms. A restricted tongue causes different symptoms for each individual baby, so an individualized and team approach involving therapists of various disciplines is critical to proper diagnosis and treatment. If it were easy to diagnose with a blood test like diabetes, then it would be easier to measure and study. Sadly, it is not taught in medical or dental schools, speech or lactation programs, or if it is, there is misinformation given out that “it will stretch out”, it won’t cause a problem, etc., ..."
We were told to see an ENT and not a dentist.
Is there a difference?
Both ENTs (Ear, Nose and Throat physicians) and dentists can treat tongue ties. The difference is not their medical degree, but rather how much specialty training they have in the diagnosis and treatment of tongue ties. Sadly, since there is a shameful lack of education in the specifics of tongue and lip ties in both medical and dental school, anyone who wants to be able to properly treat tongue ties needs to seek additional training to do so. If your pediatrician insists that you see an ENT, do your research and find out if the ENT has done any additional training in tongue ties. Ask if they understand what a posterior tongue tie is (and that they are willing to treat one). In the Boston area, it is very difficult to find any ENTs who have any speciality training in the understanding of tongue ties (especially posterior tongue ties, which many physicians deny exist in the first place). We have seen many patients who had their tongue ties "clipped" by an ENT and unfortunately the original release was insufficient and did not allow for full movement of the tongue. These patients often have to undergo a second release.
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Here are some questions you should ask a provider to see if they should be treating your tongue tie:
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What courses has the doctor taken to learn about tongue ties?
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If the provider has not taken any courses to understand the anatomy or physiology of tongue ties, or understand how it impacts function, then they do not have a full understanding of tongue ties and should not be treating them. ​
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Does the doctor release posterior tongue ties?
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Many providers unfortunately don't know what posterior tongue ties are, or (worse) they specifically deny the existence of tongue ties in the first place. This is not the kind of provider you should be trusting to do a complete tongue tie release.
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Does the doctor require that the patient is working with a feeding specialist (if the patient is an infant) or a myofunctional therapist (for child or adult?)
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If a provider is willing to release a tongue tie on a patient of any age without any kind of therapy to prepare them for a release, do not let them treat the patient! Releasing a tongue tie without either an IBCLC, SLP, OT, or other specially trained provider on board BEFORE the procedure has a very high likelihood of failure. ​
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Many physicians will insist on a referral to an ENT, but their rationale is misguided and can be dangerous and prevent patients from getting proper treatment. The bottom line is, DO YOUR RESEARCH.
Why do I need to work with a myofunctional therapist or IBCLC?
Before Dr. Heidi will treat a tongue tie, she will require confirmation that you or your child is ready to have the treatment done. This is to ensure as good an outcome as possible. In some cases, releasing a tongue tie before the patient is ready can cause symptoms to get worse. For children and adults, this could be from poor tongue strength, compensations, or fatigue - all of these can be addressed with myofunctional therapy. With infants, an IBCLC or SLP can check for other possible causes of suck dysfunction, and in many cases this can be treated with therapy to avoid the need for a tongue tie procedure at all.
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In order to ensure the best possible outcome, we always need to make sure patients are ready for treatment!